Euroasian journal of hepato-gastroenterology

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Volume 14, Number 1, January-June 2024
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Sheikh Mohammad Fazle Akbar, Hatice Yasemin Balaban

Vision for the Journal in the Second Quarter of 21st Century

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:1] [Pages No:iv - iv]

   DOI: 10.5005/ejohg-14-1-iv  |  Open Access | 



Shivaram P Singh, KC Sudhamshu, Prajna Anirvan, Ananta Shrestha, Mamun Al Mahtab

Nonalcoholic Fatty Liver Disease vs Metabolic-associated Fatty Liver Disease vs Metabolic Dysfunction-associated Steatotic Liver Disease: What's in the Name?

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:4] [Pages No:1 - 4]

Keywords: Alcohol, Fatty liver disease, Nomenclature, Prevention, South Asia, Steatotic liver disease, Stigma

   DOI: 10.5005/jp-journals-10018-1424  |  Open Access |  How to cite  | 


Original Article

Ajay Gupta, Puja Sahai, Manya Prasad, Hanuman Prasad Yadav, Gagan Srivastava, Nuneno Nakhro, Guresh Kumar, Namita Sharma

Treatment Response and Survival with Chemotherapy for Unresectable, Nonmetastatic Cholangiocarcinoma

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:4] [Pages No:5 - 8]

Keywords: Biliary tract neoplasms, Biliary tract cancers, Cholangiocarcinoma, Chemotherapy, Unresectable

   DOI: 10.5005/jp-journals-10018-1396  |  Open Access |  How to cite  | 


Background and objectives: Limited studies have dwelt upon the treatment of unresectable, nonmetastatic cholangiocarcinoma as a separate entity. Hence, the management protocols are not clearly defined for this subgroup of patients. We aimed to analyze patients treated for unresectable, nonmetastatic cholangiocarcinoma. Materials and methods: We analyzed the treatment of patients with unresectable, nonmetastatic cholangiocarcinoma retrospectively. Results: A total of 162 cases of cholangiocarcinoma were reported to our center from 2016 to 2019, out of which 54 were unresectable and nonmetastatic. Thirty patients opted for treatment and were the subjects of this study. Of 30 patients, 24 had hyperbilirubinemia, out of which 10 received chemotherapy after biliary drainage procedure. Out of 30 patients, a total of 16 patients had received chemotherapy, while 14 did not. Gemcitabine/Cisplatin was the first-line chemotherapy administered to 9 patients, whereas 5 received Gemcitabine/Capecitabine and 2 received single-agent gemcitabine. Partial response was documented in 6 patients, and 4 patients had stable disease. The median overall survival was 12.04 months in patients who had received chemotherapy and 6.02 months in those who did not receive chemotherapy (p = 0.005). The median progression-free survival was 6.53 months for patients who had received chemotherapy. The aHR for mortality with chemotherapy compared with no chemotherapy was 0.353 (95% CI: 0.154–0.807). Conclusion: The study data demonstrate that gemcitabine combined with cisplatin- or capecitabine-based chemotherapy prolongs survival in patients with unresectable and nonmetastatic cholangiocarcinoma. In patients with cholangiocarcinoma associated with jaundice, biliary drainage procedure enables giving chemotherapy. Hyperbilirubinemia persisting despite drainage procedures portends poor prognosis and represents an unmet need.


Original Article

Jasmine Samal, Anushka Soni, Amit Pandey, Gagan Chooramani, Ekta Gupta

Performance Evaluation of Determine HBsAg 2 Rapid Card Test for the Detection of Hepatitis B Surface Antigen in Clinical Samples

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:3] [Pages No:9 - 11]

Keywords: CLIA, Determine HBsAg 2, Hepatitis B, HBsAg, RDT

   DOI: 10.5005/jp-journals-10018-1403  |  Open Access |  How to cite  | 


Aim and background: Hepatitis B virus is one of the leading underlying causes of chronic liver disease. Rapid diagnostic tests with improved sensitivity and specificity for detecting hepatitis B infection could aid in large-scale community screening in resource-limited settings. This study was designed to assess the clinical performance of a rapid card test to detect HBsAg. Materials and methods: In this study, archived once-thawed serum samples were tested on the Determine HBsAg 2 card and their performance was evaluated in reference to a chemiluminescence-based assay (HBsAg qualitative assay, Abbott Diagnostics, US). Results: A total of 120 patient samples (46 confirmed HBsAg-positive and 74 confirmed HBsAg-negative) were used in this study. The overall median age of the study population was 44 years (IQR: 36–51 years), with a male gender predominance (90%). A specificity of 100% (74/74) and sensitivity of 84.7% (39/46) was observed for the Determine HBsAg 2 assay compared with the reference assay. The samples that showed false-negative results (n = 7) by the card test had HBsAg levels below the limit-of-detection of the card assay. Conclusion: The Determine HBsAg 2 assay gives rapid results in 15 minutes with good sensitivity and specificity. This makes it a good, affordable tool for large-scale screening and public health surveillance programs. Clinical significance: Accurate and cost-effective rapid card tests for early detection of Hepatitis B infection would enable quick isolation of infected cases, thus reducing transmission in the community.


Original Article

M Morsed Zaman Miah, Md Enayet Ali Pramanik, Abdur Rafi, Mira Akhter

Iron-deficiency Anemia Treatment with Ferric Carboxymaltose: A Real-world Quasi-experimental Study from Bangladesh

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:4] [Pages No:12 - 15]

Keywords: Efficacy and safety, Ferric carboxymaltose, Ferritin, Hemoglobin, Iron-deficiency anemia

   DOI: 10.5005/jp-journals-10018-1422  |  Open Access |  How to cite  | 


Gastrointestinal bleeding is the most common cause of iron deficiency in adult men and menstrual blood loss is the leading cause of iron insufficiency in women, anemia due to iron deficiency is mostly caused by blood loss. Ferric carboxymaltose (FCM) is a contemporary parenteral iron formulation that may be used therapeutically to treat anemia caused by an iron deficiency [iron-deficiency anemia (IDA)]. The main goal of the trial was to evaluate FCM's safety and efficacy in treating IDA. The Department of Hematology, Rajshahi Medical College Hospital, Rajshahi, Bangladesh participated in this quasi-experimental research, which comprised adult patients with IDA. Participants were given an intravenous (IV) infusion of 500 mg of FCM, diluted in 100 mL of 0.9% normal saline, throughout a 30-minute period after their participation. The second dosage of FCM was administered after a 7-day period of the first dose. The comparison of the outcomes [hemoglobin (Hb) level, serum ferritin level, and other hematological parameters] between the baseline and day 14 postintervention was done using a paired t-test. Compared to baseline, patients’ Hb levels rose considerably (p = 0.001) after FCM. Aside from serum ferritin level, additional hematological parameters that sharply increased were red blood cells (RBCs) count, mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width – coefficient of variation (RDW-CV), and iron indicators. The experiment recorded mild adverse effects such as fever, headaches, and gastrointestinal issues including vomiting, diarrhea, and constipation, but no significant adverse events. In summary, IDA may be effectively treated with FCM, a safe and secure IV medication that has no major negative effects.


Original Article

Nazish Butt, Lubna Kamani, Hanisha Khemani

Hepatitis B Risk Factors are Frequently Present in Children at Jinnah Postgraduate Medical Centre in Karachi

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:4] [Pages No:16 - 19]

Keywords: Blood-borne transmission, Hepatitis B virus, Horizontal transmission, Perinatal transmission

   DOI: 10.5005/jp-journals-10018-1418  |  Open Access |  How to cite  | 


Background: Infection with the hepatitis B virus (HBV) poses a serious threat to global public health. More than 300 million instances of chronic hepatitis are brought on by it, which is the primary cause of liver disease. This study was conducted to determine the risk factors of HBV in children at Jinnah Postgraduate Medical Centre, Karachi, Sindh, Pakistan. Materials and methods: This cross-sectional study was conducted at the Department of Gastroenterology, Jinnah Postgraduate Medical Centre, Karachi, Sindh, Pakistan from January 2019 to April 2022. A total of 134 children aged below 16 years with HBV were recruited in this study. Demographic information was recorded. Screening for HBV was done in all patients. Investigations including liver biochemistry, hepatitis B surface antigen (HBsAg), and HBV DNA polymerase chain reaction (PCR) were conducted in the hospital along with a complete blood count and ultrasound whole abdomen. All information was collected on a predesigned proforma and evaluated using statistical package for the social sciences (SPSS), version 25.0, software. Results: The mean age of patients was 11.02 ± 2.19 years. There were 57.46% males. The frequent risk factor was vertical transmission in 47% of children followed by blood transfusion in 23.9% of children, horizontal transmission in 13.4% of children, and prior history of surgical or dental intervention in 17.2% of children. Conclusion: In this study, vertical transmission was the most common route of transmission of HBV. Additionally, 11% of family members were HBV positive. None had concomitant hepatitis C virus (HCV) and HDV infection. All pregnant females should be screened. Children on chronic blood transfusion therapy should be screened annually. Additionally, birth-dose HBV vaccination should be implemented as a key step in HBV prevention among Pakistani children.


Original Article

Er Ramazan Erdem, Mehmet Bektaş, Zeynep M Ellik, Koray Ceyhan

Use of Endoscopic Ultrasound Elastography to Differentiate between Gastrointestinal Stromal Tumor and Leiomyoma Localized in the Upper Gastrointestinal Tract

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:4] [Pages No:20 - 23]

Keywords: Endoscopic ultrasound elastoghraphy, Gastrointestinal stromal tumor, Giovannini's classification, Leiomyoma, Strain ratio

   DOI: 10.5005/jp-journals-10018-1419  |  Open Access |  How to cite  | 


Background: Gastrointestinal stromal tumors (GISTs) have malignant potential. Distinction of GISTs from leiomyoma is important to the decision of follow-up or treatment for upper gastrointestinal tract subepithelial lesions (SELs). There are few studies on the evaluation of gastrointestinal SELs with endoscopic ultrasound (EUS) elastography. Aims: To evaluate the efficiency of strain ratio (SR) measurement and Giovannini's classification (Gc) by EUS elastography in differentiating GISTs from leiomyomas. Materials and methods: Twenty-three lesions with histopathological diagnoses of 13 GISTs and 10 leiomyomas were evaluated. The lesions’ SR values were obtained from EUS reports retrospectively. Giovannini's classification was performed according to the elastography images recorded in the system. The effectiveness of SR and Gc in the distinction between GIST and leiomyomas was evaluated. Results: Twelve of the GISTs and 3 of the leiomyomas were with scores 4 and 5 according to Gc (p = 0.006). Gastrointestinal stromal tumors had a higher SR than leiomyomas (p = 0.001). For the diagnosis of GISTs, sensitivity/specificity/diagnostic accuracy were 92.3%/80%/87% for SR alone, 92.3%/70%/82.6% for Gc alone, and 84.6%/80%/82.6% for the use of both SR and Gc. Conclusions: This is the first study in which semi-quantitative (SR) and qualitative (Gc) methods were evaluated together for the distinction of GISTs and leiomyomas. The sensitivity of SR alone for diagnosing GIST is higher than that of Gc alone or the combination of both methods. Although SR alone does not diagnose GIST, it can be used as an auxiliary method in biopsy and follow-up decisions.


Original Article

Nazish Butt, Bushra Shahid, Sehrish Butt, Murk Mujahid Channa, Sehrish Reema, Ali Akbar

Clinical Spectrum of Celiac Disease among Adult Population: Experience from Largest Tertiary Care Hospital in Karachi, Pakistan

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:6] [Pages No:24 - 29]

Keywords: Chronic diarrhea, Classical celiac disease, Refractory anemia

   DOI: 10.5005/jp-journals-10018-1420  |  Open Access |  How to cite  | 


Introduction: Celiac disease (CD) is a systemic autoimmune enteropathy triggered by dietary gluten in genetically susceptible individuals. Celiac disease affects 0.6–1.0% of the population worldwide. The prevalence of CD in Pakistan is yet unknown due to under diagnosis and lack of awareness. Objective: To determine a vast variety of presenting features in subtypes of CD to overcome the burden of disease. Materials and methods: This was a prospective, comparative, cross-sectional study conducted at Gastroenterology department of Jinnah Postgraduate Medical Center, Karachi from December 2022 till June 2023. This study included all adult patients ≥18 years diagnosed with CD on the basis of clinical presentation, positive IgA and IgG anti-transglutaminase antibodies (value >12 IU/mL detected by ELISA followed by small intestinal biopsy classified as per Marsh criteria. The data obtained were analyzed on the statistical software SPSS version 23. Descriptive statistics were obtained by frequencies and percentages. Results: About 142 patients were enrolled in the study, 103 (91.5%) had classical CD (CCD) whereas 36 (25%) had non-classical (NCCD). About 89 (62.7%) were females and 53 (37.3%) were males. The mean age was found to be 23 ± 6 years. Nutritional deficiencies including anemia, B12, folate, osteopenia and low body mass index (BMI) <18 was found more in CCD group as compared with NCCD group with significant p-values. Titers of anti-TTG between CCD and NCCD were not statistically significant. Hypothyroidism and PCOS were the most common associated conditions observed in adult CD patients. Conclusion: In conclusion, CD in adults and has diverse presentations. Adults with unexplained extra-intestinal symptoms like anemia and bone pain should be investigated for CD.


Original Article

Nikhil Raj, Anshuman Pandey, Raja Roy, Manodeep Sen, Jyotsna Agarwal

Proton Nuclear Magnetic Resonance (1H NMR) Metabolomics Study in Serum, Urine, and Cystic Fluid for Differentiating Fertility and Staging of Intra-abdominal Hydatid Cyst in Adults

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:5] [Pages No:30 - 34]

Keywords: 1H NMR, Cystic echinococcosis, Hepatic cyst, Hydatid disease, Metabolomics

   DOI: 10.5005/jp-journals-10018-1416  |  Open Access |  How to cite  | 


Background: Cystic echinococcosis (CE) is a parasitic zoonosis caused by the tapeworm Echinococcus granulosus. Over the past few years, a lot of research has been done on liver illnesses using metabolomics techniques to identify biomarkers which could identify the diseases in its early stages. The present study was done to explore biomarkers in serum, urine, and cystic fluid which would help in differentiating, staging, and assessing fertility of intra-abdominal hydatid cyst by using proton nuclear magnetic resonance (1H NMR) metabolomics. Materials and methods: In the study, 28 subjects (16 cases and 12 controls) were enrolled. Staging of hydatid cysts was performed using ultrasonography. In patients complying with case and control definition, blood, urine, and cystic fluid were collected for complete blood count, urine culture, Echinococcus IgG enzyme-linked immunosorbent assay (ELISA), and metabolomic analysis. The 17, 15, and 11 metabolites in serum, urine, and cystic fluid samples were quantified, respectively, to differentiate between case and control group. Results: In this study, we observed that there was a significant downregulation of succinate metabolite in urine samples of cases, down-regulation of five metabolites (isoleucine, valine, histidine, tyrosine and formate) and upregulation of alanine in cystic fluid of cases. Conclusion: Current study demonstrates that metabolomics can be used non-invasively for rapid diagnosis of CE. This is one of the very few studies, which used1H NMR spectroscopy, to analyze the profile of metabolites in serum, urine, and cystic fluid in cases of CE and controls.


Original Article

Priyansh D Bhayani, Sarojini A Parameswaran, Kallippatti R Palaniswamy, Paramasivan Piramanayagam, Natarajan Murugan

Is Aspartate Aminotransferase to Platelet Ratio Index a Better Noninvasive Score for Predicting Advanced Fibrosis in Nonalcoholic Fatty Liver Disease Patients?

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:5] [Pages No:35 - 39]

Keywords: Aspartate aminotransferase to platelet ratio index score, FibroScan, Fibrosis-4 score, Nonalcoholic fatty liver disease, Nonalcoholic fatty liver disease fibrosis score

   DOI: 10.5005/jp-journals-10018-1425  |  Open Access |  How to cite  | 


Background: In the 21st century, nonalcoholic fatty liver disease (NAFLD) is the most prevalent liver disorder. The prevalence of NAFLD within the general population in India ranges from 9 to 53%. The gold standard for assessing the severity of liver fibrosis is liver biopsy. However, due to various difficulties involved with liver biopsy, it is imperative to identify different non-invasive tools that can replace liver biopsy. Methodology: A prospective observational study of 130 patients meeting the inclusion criteria for NAFLD was done for a period of 18 months. We aimed to compare the performance characteristics of different noninvasive scores [fibrosis-4 (FIB-4) score, nonalcoholic fatty liver disease fibrosis score (NFS), and aspartate aminotransferase to platelet ratio index (APRI)] in predicting advanced fibrosis as assessed by FibroScan. Results: In the study, 76.9% of patients were male. Advanced fibrosis was seen in 12.3% of the patients. Majority of the patients with advanced fibrosis had metabolic syndrome. Based on the area under the receiver operating characteristic curve (AUROC), the new cut-off for ruling out advanced fibrosis for FIB-4, NFS, and APRI were 1.18, −0.9, and 0.65, respectively, and APRI had the best AUROC (0.768). Conclusion: Abnormal glycemic status and metabolic syndrome were risk factors for advanced fibrosis. The newly derived cut-offs for the FIB-4 score, NFS score, and APRI score had a better Negative predictive value compared to the original cut-offs.


Original Article

Abbas Ali Tasneem, Taha Yaseen, Syed Mudassir Laeeq, Zain Majid, Nasir Hassan Luck

Pancreatobiliary Lymphadenopathy: Etiology, Location, and Factors Predicting Good Yield of Endoscopic Ultrasound-guided Biopsy

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:4] [Pages No:40 - 43]

Keywords: Endoscopic ultrasound, Etiology, Macroscopic on-site evaluation, Pancreatobiliary lymph nodes

   DOI: 10.5005/jp-journals-10018-1433  |  Open Access |  How to cite  | 


Introduction: Pancreatobiliary lymphadenopathy (PBL) may be due to a number of benign or malignant causes. Tissue sampling of these lymph nodes (LN) can be possible with the help of endoscopic ultrasound (EUS). Aim of this study was to identify the etiology of the PBL, morphology, and factors predicting good yield of biopsy with EUS. Materials and methods: All patients found to have pancreatobiliary lymph node (PBLN) enlargement (>10 mm) on abdominal imaging and referred for EUS-guided biopsy were included in this prospective observational study. The facility of rapid on-site evaluation (ROSE) was not available. Adequacy of the tissue specimen was assessed by the endoscopist with macroscopic on-site evaluation (MOSE) and then sent to histopathologist for final diagnosis. Factors predicting good yield of biopsy were then analyzed. Results: Of the total 87 patients with PBL, 54 (62.1%) were males. Mean age of the patients was 52.0 (±13.4) and range 18–80 years. The commonest locations of PBL were porta hepatis 37 (42.5%), peripancreatic 24 (27.6%), celiac 16 (18.4%), and others 10 (11.5%). Histological reports showed: neoplastic tissue in 34 (39.1%), non-neoplastic in 20 (23%), normal lymphoid tissue (27.6%) and suboptimal in 9 (10.3%). Among the 34 neoplastic causes, 26 had metastatic adenocarcinoma, 5 had lymphoma, and 3 had metastatic neuroendocrine tumors. Among the 20 non-neoplastic causes, 10 had tuberculosis, 4 had anthracosis, and 6 had other findings. Factors predicting good yield of biopsy were a PBLN size ≥12 mm and satisfactory MOSE on both univariate [PBLN (p = 0.005); MOSE (p < 0.0001)] and multivariate [PBLN (p = 0.011); MOSE (p < 0.0001)] analysis. Conclusion: The commonest etiology of PBLN enlargement was metastatic adenocarcinoma among the neoplastic causes and tuberculosis among the non-neoplastic causes. The most common PBLNs approached by EUS were in portahepatis and peripancreatic regions. A good biopsy yield can be predicted with PBLN size of ≥12 mm and a satisfactory MOSE.


Original Article

Jair Diaz-Martinez, Nayelli Pérez-Correa

Postcholecystectomy Duodenal Injuries, Their Management, and Review of the Literature

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:7] [Pages No:44 - 50]

Keywords: Complications, Duodenal injuries, Duodenum, Laparoscopic cholecystectomy, Perforation

   DOI: 10.5005/jp-journals-10018-1427  |  Open Access |  How to cite  | 


Backgrounds: Laparoscopic cholecystectomy (LC) is the gold standard for treating gallstones; however, it is not free of complications. Postcholecystectomy duodenal injuries are rare but challenging complications after cholecystectomy. The objective of this study was to analyze the management of postcholecystectomy duodenal injuries and to review the related literature. Materials and methods: An observational and retrospective study was conducted. We included all patients with postcholecystectomy duodenal injuries treated at a reference center, from January 2019 to December 2023. In addition, a review of the literature was carried out. Results: Fifteen patients were found, mostly women; with gallbladder wall thickening on ultrasound (mean of 8 mm). The majority were emergency (n = 12, 80%) and LCs (n = 8, 53.33%). Cholecystectomies were reported to be associated with excessive difficulty (n = 10, 66.66%). The most injured duodenal portion was the first portion (n = 9, 60%), and blunt dissection was the most common mechanism of injury (n = 7, 46.66%). Most of these injuries were detected in the operating room (n = 9, 60%), and treated with primary closure (n = 11, 73.33%). Three patients with delayed injuries died (20%). According to the literature reviewed, 93 duodenal injuries were found, mostly detected intraoperatively, in the second portion, and treated with primary closure. A minority of patients were treated with more complex procedures, for a mortality rate of 15.38%. Conclusion: Postcholecystectomy duodenal injuries are rare. Most of these injuries are detected and repaired intraoperatively. However, a high percentage of patients have high morbidity and mortality.


Original Article

Nazish Butt, Muhammad T Usmani, Riaz Hussain, Saba Mughal, Fakhar A Qazi Arisar

Efficacy of Pegylated Interferon-alpha-2a in Chronic Hepatitis Delta: Experience from a Tertiary Care Hospital in Karachi

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:5] [Pages No:51 - 55]

Keywords: Hepatitis delta virus, Outcomes, Pakistan, Treatment, Virological response

   DOI: 10.5005/jp-journals-10018-1431  |  Open Access |  How to cite  | 


Background: Chronic hepatitis D (CHD) along with chronic hepatitis B (CHB) is an important cause of morbidity and mortality in patients with cirrhosis. It is a potentially curable infection that has long awaited a good treatment option. Objective: To ascertain the efficacy of pegylated interferon (PEG-IFN)-alpha-2a in patients suffering from CHD. A tertiary care hospital experience from Pakistan. Materials and methods: The study included 207 CHD polymerase chain reaction (PCR)-positive patients treated with PEG-IFN-alpha-2a between July 2020 and October 2022. Virological response rate (PCR negative) at weeks 24 and 48 was the primary endpoint. Secondary outcomes included partial response (>2 log reduction in PCR) and treatment failure rate (<2 log reduction in PCR). Results: A total of 187 patients started PEG-IFN therapy, and 148 patients completed the assigned 48 weeks of therapy. Patients’ mean age was 25.7 years with 65% being males. The virological response rate was 40.5% at week 24 and 32.4% at week 48. The partial response rate was 24% at both weeks 24 and 48. The treatment failure rate was 36% at week 24 and 44% at week 48. Hemoglobin, white blood cell (WBC) count, and total bilirubin were found to be predictive of treatment response. Side effects led to treatment discontinuation among eighteen patients and one patient died due to hepatic failure. Conclusion: Therapy with PEG-IFN-alpha-2a shows suboptimal outcomes in patients with CHD. There is a strong need for more effective alternate therapies for CHD patients.


Original Article

Azar Abiyev, Barış Tuzcu, Gülden Bilican, Harun Küçük, Serkan Dumanlı, Seçkin Özgül, Mustafa Ergin, Güner Kılıç, Ali Karataş, Murat Kekilli

Combination of Precut Techniques in Difficult Biliary Cannulation

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:4] [Pages No:56 - 59]

Keywords: Difficult biliary cannulation, Needle-knife sphincterotomy, Transpancreatic septotomy

   DOI: 10.5005/jp-journals-10018-1428  |  Open Access |  How to cite  | 


Background: Selective biliary cannulation (SBC) is a prerequisite for successful endoscopic retrograde cholangiopancreatography (ERCP). SBC has the potential to fail in as many as 20% of cases, even with skilled endoscopists. Precut incision techniques like needle-knife sphincterotomy (NKS) and transpancreatic septotomy (TPS) can be used in cases where standard cannulation techniques fail. However, these precut techniques may also fail in some cases. We aimed to evaluate the procedural success of the combined TPS + NKS technique in difficult biliary cannulation. Patients and methods: The study included 289 patients who underwent ERCP with precut techniques from 2017 to 2022. Patients were classified into the following three groups and evaluated retrospectively in terms of cannulation success, and ERCP-related adverse effects: Transpancreatic septotomy, NKS, and TPS + NKS; statistical package for the social sciences (SPSS), version 29.0, software was used to analyze the data. Results: The success rate of SBC was 69% in the TPS group, 75.3% in the NCS group, and 87% in the TPS + NCS group. There was no significant difference between the NKS and TPS + NKS groups. Cannulation success in both NKS group and NKS + TPS groups was significantly higher than in the TPS group (p < 0.001). Complication rates were similar. Conclusion: In cases where standard sphincterotomy and precut techniques fail, a second precut technique can be used. A previous TPS does not prevent NKS.


Original Article

Nikhil Raj, Jyotsna Agarwal, Vikramjeet Singh, Manodeep Sen, Anupam Das

Healthcare-associated Diarrhea due to Clostridioides difficile in Patients Attending a Tertiary Care Teaching Hospital of North India

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:5] [Pages No:60 - 64]

Keywords: Clostridioides difficile, Diarrhea, Healthcare-associated infection, Glutamate dehydrogenase

   DOI: 10.5005/jp-journals-10018-1429  |  Open Access |  How to cite  | 


Background: Healthcare-associated diarrhea (HCAD) is diarrhea that develops at least after 3 days of hospitalization, with the most common infectious cause being Clostridioides difficile. Over the last decade, there has been a remarkable growth in the frequency and severity of C. difficile infection (CDI), making it one of the most prevalent healthcare-associated infections. This study aimed to analyze the prevalence and risk factors associated with CDI. Materials and methods: A total of 107 patients with clinical suspicion of having HCAD were included in this study. Enzyme-linked fluorescent assay (ELFA) technique-based glutamate dehydrogenase (GDH) and toxin A/B assay were used as per the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) for diagnosing CDI. The details about associated comorbidities were retrieved from the hospital information system records. The presence of risk factors was noted. Risk factors associated with CDI were looked for. Results: Out of the 107 stool samples received in the microbiology laboratory from patients with suspected HCAD eight (7.6%) samples were positive for CDI. The most frequent comorbidity observed in these patients was renal illness (acute or chronic kidney disease). In this study, a total of 7/8 cases were on multiple antibiotics most common being carbapenem. Conclusion: The 6-year prevalence of CDI observed in this study was found to be 7.6% risk factors, associated with CDI were kidney disease, diabetes mellitus, malignancy, and exposure to broad-spectrum antibiotics.


Original Article

Batsukh Badamnachin, Tegshjargal Badamjav, Ganchimeg Dondov, Gantogtokh Dashjamts, Chinbayar Tserendorj, Tulgaa Lonjid, Bilegtsaikhan Tsolmon, Batbold Batsaikhan

The Dynamics of the Prevalence of Acute Viral Hepatitis and the Strategies against Viral Hepatitis in Mongolia

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:5] [Pages No:65 - 69]

Keywords: Acute hepatitis, Hepatitis B virus, Hepatitis C virus, Hepatitis D virus 5, Mongolia, Viral hepatitis

   DOI: 10.5005/jp-journals-10018-1435  |  Open Access |  How to cite  | 


Background: Hepatocellular carcinoma (HCC) is the most common cancer in Mongolia. The relative importance of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in HCC etiology is known to vary greatly from one part of the world to another. Principally, 95% of HCC patients have chronic viral hepatitis, including 53% hepatitis B virus, 38.9% HCV, and 5.6% have HBV/HCV coinfection. Hepatitis D virus (HDV) infection is widely spread in our country, anti-HDV has been found in more than 25% of carriers who have HBsAg. Materials and methods: We analyzed data of patients who had been diagnosed with acute viral hepatitis in the Department of adult hepatitis, National Center for Communicable Diseases in Mongolia from 1952 to 2018. Results: A total of 318,831 cases of acute viral hepatitis were registered in Mongolia between 1981 and 2019, which is 34.9 cases per 10,000 population. Of these, 265,931 cases of acute viral hepatitis A, or 28.6 per 10,000 populations, 48,855 cases of acute viral hepatitis B, or 5.5 cases per 10,000 populations, and 2,607 cases of acute viral hepatitis C, or 0.4 cases per 10,000 populations were recorded. Conclusion: The prevalence of viral hepatitis in our country was the highest in 1981–1991, but since 2012, the prevalence of infection has steadily decreased. In Mongolia, since 1960, multifaceted programs and activities to combat viral hepatitis have been successfully implemented at the national level.


Original Article

Bilal Ahmad, Mohd Fazl Ul Haq, Mubashir Ah Shah, Fazlul Q Parray, Gowhar Aziz Bhat, Rauf Ah Wani

Early Postoperative Small Bowel Obstruction after Colorectal Surgery: Incidence and Exploratory Analysis of Potential Risk Factors

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:5] [Pages No:70 - 74]

Keywords: Abdominal surgeries, Acute abdomen, Colorectal surgery, Early postoperative small bowel obstruction, Gut obstruction, Laparotomy

   DOI: 10.5005/jp-journals-10018-1423  |  Open Access |  How to cite  | 


Background: Early postoperative small bowel obstruction (EPSBO) is a common complication following colorectal surgery, which can significantly impact patient outcomes. This study aimed to investigate the incidence of EPSBO and identify potential risk factors among patients who underwent colorectal surgery. Methods: A descriptive study was conducted on a cohort of 100 patients who underwent colorectal surgery at a tertiary center at SKIMS, Srinagar, Jammu & Kashmir, India. Descriptive, bivariate, and predictive screening analyses were performed to examine patient characteristics, assess association between different relevant variables and EPSBO, and identify significant predictors, respectively. Results: Our study included a total of 100 patients, with a mean age of 50.39 years. Postsurgery, 11% of the individuals in the cohort developed EPSBO. Early postoperative small bowel obstruction developed around 4.30 days after surgery, and radiographic data revealed dilated gut loops in 72.70% of EPSBO cases. Bivariate analysis revealed significant association between EPSBO and variables such as previously operated, medical comorbidities, smoking status, anemia, neoadjuvant chemoradiotherapy (NACRT), bowel preparation, operative procedure, surgery duration, and type of anastomosis (p < 0.05). History of previous bowel habits, previously operated, perioperative bowel preparation, and blood transfusion were identified as the most influential predictors of EPSBO in the predictive screening study. Conclusion: This study provides insights into the incidence of EPSBO and its potential risk factors for postcolorectal surgery among patients. The findings emphasize the need to take the patient's history of past bowel habits and other factors into account when determining the risk of EPSBO. Future studies should go deeper into these correlations and consider treatments to reduce the occurrence of EPSBO in this patient population.


Original Article

Mohd Fazl Ul Haq, Gowhar Aziz Bhat, Munir Ah Wani, Ajaz Ah Malik, Mohd Israr Ul Haq, Mohd Ehsan Ul Haq

Outcome of Obstructing vs Nonobstructing Colorectal Carcinomas: Comparative Study at Tertiary Care Hospital in Kashmir

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:6] [Pages No:75 - 80]

Keywords: CA colon, CA rectum, Colorectal carcinoma, Emergency, Malignant bowel obstruction, Nonobstructing cancer, Obstructing cancer

   DOI: 10.5005/jp-journals-10018-1421  |  Open Access |  How to cite  | 


Background: Colorectal cancer (CRC) is the commonly diagnosed malignancy presenting either in obstruction or without obstruction. Bowel obstruction (BO) is usually a complication of advanced cancer, significantly reducing the quality of life. We aimed to study the outcomes of these obstructed colorectal cancers requiring emergency intervention and compare it with nonobstructed cancers. Materials and methods: In our observational comparative study, patients were divided into groups on basis of their presentation and site of lesion: nonobstructing colon group/obstructing colon group nonobstructing rectum group/obstructing rectum group. Results: A total of 232 patients with known modes of presentation between 2015 and 2018 were included; 144 colonic, 88 rectal carcinomas with 71 being completely obstructive ones. Our study showed higher recurrence in obstructive groups with local recurrence being more common. The median interval for recurrence was early in obstructive group (p < 0.001*). The overall 5-year survival rates were better in Nonobstructing colon group, (p = –0.046* in OR vs NOR) (p = –0.031* in OC vs NOC). 5-year disease-free survival rates statistically insignificant (p = 0.203 in NOC and OC groups), (p = 0.307 in NOR and OR groups). Immediate post-op, complications except for SSI, there was no significant difference between the two groups. Our study showed higher proportion of R0 resection in NOC groups as compared with obstructive groups (p = 0.021* in in OC vs NOC and p = 0.037* in OR vs NOR) with better lymph node retrieval in NOC groups. Conclusion: On comparing outcome of patients who had completed multi-modal therapy in both groups, there was significantly better outcome for patients who have presented without obstruction.


Original Article

Jibreel Y Shah, Imad Banday, Hanna Z Hamdani, Mohd Fazl Ul Haq, Fazl Q Parray, Meeran Banday, Gowhar Aziz Bhat

A Study of Predictors of Failure of Nonoperative Management of Ileocolic Intussusception in Children

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:5] [Pages No:81 - 85]

Keywords: Acute abdomen, Hydrostatic reduction, Intussusception, Outcomes, Pediatric emergency, Pediatric surgery

   DOI: 10.5005/jp-journals-10018-1432  |  Open Access |  How to cite  | 


Background: Surgery remains the mainstay in treating intussusception in developing nations. A correspondingly high bowel resection rate exists despite a shift to nonoperative reduction in high-income countries. We aimed to study the clinical profile of the patients with intussusception presenting to our hospital and to assess the clinical and radiological predictors of success or failure of nonoperative management of intussusception. Materials and methods: This prospective study was conducted in the Department of Pediatric Surgery over a period of 3 years and included a total of 118 patients who presenting to our emergency division with features suggestive of intussusception and were managed accordingly either with hydrostatic reduction or by surgical intervention. Results: We observed that the majority of the patients were males (65.5%). The mean age was 13.54 months. Intermittent pain was the most common symptom. Both pain and vomiting did not affect the outcome. Lab parameters like raised total leukocyte counts (TLC), C-reactive protein (CRP) and lactate levels were significantly associated with failure of hydrostatic reduction. Patients with air fluid levels on X-ray were more likely to end up in surgery. Ultrasound findings of bowel wall edema, aperistaltic gut loops and a pathological lead point was associated with failure of hydrostatic reduction as well. The overall success rate of hydrostatic reduction was 85.5%. Conclusion: Hydrostatic reduction of intussusception is a safe and effective method of management of intussusception whenever indicated. Factors that might reduce the chance of its success include continuous pain, irritability, tenderness, deranged lab parameters like TLC, CRP and lactate levels, air fluid levels on X-ray, bowel wall edema, aperistalsis and the presence of a lead point.



Rajesh Upadhyay, Navin K Soni, Ashwin A Kotamkar, Azra Naseem, Aaditi Phadke, Shreshth Nayar, Shailesh Pallewar, Parvan Shetty, Ashish Mungantiwar, Sunil Jaiswal, Amit Qamra

High Dose Pantoprazole for Gastroesophageal Reflux Disease: Need, Evidence, Guidelines and Our Experience

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:6] [Pages No:86 - 91]

Keywords: Dual-drug release, Gastroesophageal reflux disease, High dose, Pantoprazole, Proton pump inhibitors

   DOI: 10.5005/jp-journals-10018-1426  |  Open Access |  How to cite  | 


Gastroesophageal reflux disease (GERD) has a pooled prevalence of 15.2% in India with varying presentation in different subset of patients. The approach towards the management of GERD includes use of monotherapy or a combination of OTCs like antacids and/or prescription drugs like H2 receptor antagonists and proton pump inhibitors (PPI). Better efficacy and safety profile of PPIs have contributed to its wide spread use as compared with other drugs for the same indication. Among PPIs, most of the healthcare professionals prefer to prescribe pantoprazole in India. Standard dose of Pantoprazole (40 mg) is unable to meet the needs in case of extraesophageal symptoms, partial responders, patients with concomitant use of non-steroidal anti-inflammatory drugs (NSAIDs), or severe presentation in cases of overweight/obese patients. Multiple guidelines recommend doubling the dose of PPI in such cases. Twice daily dosing of PPI may reduce compliance. Thus, there is a need for a higher dose of Pantoprazole (80 mg) to be prescribed once daily in these cases so that improved compliance leads to better outcomes. The use of dual release Pantoprazole 80 mg may help to improve compliance and also enhance the time for which acid suppression takes place. In this review, we discuss the use of higher dose PPI based on scientific evidence and experience of clinicians for the same.



Vaibhavi S Patel, Safa F Mahmood, Kunal H Bhatt, Richisha M Khemkar, Devanshi R Jariwala, Bilal Harris, Mirna M George, Reuel A Kurudamannil, Onyekachi E Anyagwa, Rajeeka S Tak, Maha Kassem

Ursodeoxycholic Acid's Effectiveness in the Management of Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-analysis

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:7] [Pages No:92 - 98]

Keywords: Meta-analysis, Nonalcoholic fatty liver disease, Systematic review, Ursodeoxycholic acid

   DOI: 10.5005/jp-journals-10018-1434  |  Open Access |  How to cite  | 


Aim: This meta-analysis's objective was to assess the effectiveness of ursodeoxycholic acid (UDCA) in the management of nonalcoholic fatty liver disease (NAFLD). Methods: Electronic databases like PubMed, Embase, Scopus, and Cochrane Library were thoroughly looked for randomized controlled trials determining ursodeoxycholic acid's (UDCAs) effectiveness on the serum liver function tests in NAFLD patients. After screening, seven randomized controlled trials were incorporated overall. Utilizing a fixed effects model, quantitative data synthesis was performed in R version 4.3.1. Results: The meta-analysis showed significant reductions in alanine transaminase (ALT) (p ≤ 0.0001), aspartate transaminase (p = 0.0009), and gamma-glutamyl transferase (GGT) (p ≤ 0.0001) after UDCA therapy. However, significant reductions in bilirubin (p = 0.6989) and alkaline phosphatase (ALP) (p = 0.1172) levels were not noted. Sensitivity analysis by removing the studies with some concerns of bias was successful in demonstrating a remarkable reduction in heterogeneity for aspartate transaminase and ALP, which was also observed while performing the subgroup analyses via dosage. Conclusion: Ursodeoxycholic acid was beneficial in patients diagnosed with NAFLD as it significantly reduced aspartate transaminase, ALT and GGT levels. However, more randomized controlled trials are required to be conducted in the future to increase the certainty of the evident findings. Clinical significance: This meta-analysis strengthens the evidence about the reductions in AST, ALT, and GGT levels observed with ursodeoxycholic acid therapy in NAFLD patients by pooling the data together from the latest RCTs thus proving its hepatoprotective effects which can be beneficial in preventing the associated complications.



Ram Y Prabhoo, Uday A Pai, Arun Wadhwa, Bhanu V Pillai, Chris D'souza, Manav Wadhawan, Manish Bhatnagar, Meena R Prabhoo, Sadanand Shetty, Venkatesh P Seshadri, Shrish Bhatnagar, Subhash C Manchanda, Vijay Kher

Multidisciplinary Consensus for Rationalizing the Use of Acid Suppressants in Children and Adults: CONFOR

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:21] [Pages No:99 - 119]

Keywords: Deprescribing, Gastrointestinal, H2RAs, Proton pump inhibitors, Ranitidine, Side effects

   DOI: 10.5005/jp-journals-10018-1430  |  Open Access |  How to cite  | 


The use of acid suppression therapy (AST) is a common approach for managing a wide spectrum of acid peptic disorders. Histamine type 2-receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) are the most widely prescribed AST in routine clinical practice. However, an exponential surge in the prescriptions of PPIs, such as Omeprazole, Esomeprazole, Pantoprazole, Lansoprazole in recent years and their associated adverse effects have raised concern about their inappropriate and overuse, both in children and adults. To address these issues, a three-step modified Delphi polling process was employed to establish best practice consensus statements for rationalizing the use of acid suppressants. A multidisciplinary expert panel of 13 health professionals across medical specialties, including gastroenterologists, hepatologists, pediatric gastroenterologists, pediatricians, otolaryngologists, cardiologists, nephrologists, gynecologist and orthopedists actively contributed to this collaborative process of consensus development. The expert panel proposed 21 consensus statements providing best practice points on the general use and safety of acid suppressants based on a comprehensive review of scientific literature and clinical expertise. The panel also collaboratively developed a PPI deprescribing algorithm. Altogether, this consensus paper offers evidence-based recommendations and guidance for the rational use of acid suppressants with a blueprint for deprescribing PPIs. This consensus paper contributes to aiding primary care practitioners in improving patient outcomes and minimizing healthcare costs. Additionally, it enhances patient safety and curtail inappropriate usage.



Anushka Verma, Amol S Dahale, Prashant Gopal, Suruchi Mandrekar, Reshu Aggrawal, Nanda Kachare

Colonoscopy Findings of Uncomplicated Enteric Fever Mimicking Koch's Disease

[Year:2024] [Month:January-June] [Volume:14] [Number:1] [Pages:4] [Pages No:120 - 123]

Keywords: Colonoscopy, Enteric fever, Tuberculosis

   DOI: 10.5005/jp-journals-10018-1417  |  Open Access |  How to cite  | 


Enteric fever is a common occurrence in Southeast Asia with a myriad of presentations. Partial treatment often leads to prolonged illness. Along with this, bowel imaging often confounds the picture with tuberculosis. Colonoscopy and biopsy may help to differentiate from tuberculosis. The data on colonoscopy is scarce in enteric fever and is mostly available from case reports of gastrointestinal (GI) bleeding. We have described three cases of enteric fever with GI involvement mimicking tuberculosis. The colonoscopy picture is characteristic of pinkish-bluish ileal mucosa, with edema and decreased distensibility, along with multiple superficial ulcers. The ileocecal valve was involved in all three cases. The ascending colon was involved in two cases. There was complete resolution of lesions after treatment on follow-up.


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